By Tara Bannow • The Bulletin

Teenage drug experimentation doesn’t always start with a joint or a beer. For some, it’s over-the-counter cold medicine.

“There is that cultural acceptance that, ‘You can buy it in a pharmacy, so it’s safe,’” said Megan Sergi, outpatient program director for Rimrock Trails Adolescent Treatment Services, an addiction treatment provider for kids ages 12 to 24 with offices in Bend, Redmond and Prineville.

Rimrock Trails administrators say they’ve had six adolescents referred to them since April because they overdosed on over-the-counter cough and cold medicine that contained an ingredient called dextromethorphan, a cough suppressant that produces a high if taken in large quantities. Too much, however, can cause seizures, loss of consciousness, brain damage and irregular heartbeat. Statewide, the Oregon Poison Center saw 488 reports of emergency room visits last year stemming from intentional DXM ingestion.

Dr. Robert Hendrickson, the Poison Center’s associate medical director, said that number underestimates the problem, as not all cases get reported to his agency.

“This is not uncommon,” said Hendrickson, also an emergency medicine professor and medical toxicologist at Oregon Health & Science University. “This is something we see frequently with adolescents.”

Easy access

The overdoses tend to come in waves as more teens catch on, but Rimrock’s leaders say they’re concerned pharmacies are making the drugs too easy for kids to pocket when no one is looking.

“Kids can get their hands on it pretty easily,” Sergi said. “They can steal it.”

There is no law in Oregon that requires pharmacies to keep the medications in secure areas, such as behind the pharmacy counter, but several chain pharmacies, such as Safeway, Walgreens and Fred Meyer, require customers be 18 years old to buy them.

For his part, Hendrickson said he thinks making stores keep DXM-containing products behind their pharmacy counters would be a good move. That maneuver was effective when it was done with cold medicines containing pseudoephedrine, an ingredient used to make methamphetamine. And many hardware stores keep spray paint, which teens also have huffed to get high, behind locked counters, he said.

“I think that would be a very reasonable thing,” he said. “The downside is it inconveniences people who want to use it for the regular use, but I think that’s a relatively small price to pay.”

Marcus Watt, executive director of the Oregon Board of Pharmacy, said his agency would be open to discussing such a change if a problem were brought to its attention.

“To my knowledge, I’ve not heard anything about overdoses or an increase or a spike, so it’s kind of news to us,” he said.

Out of the ordinary

DXM is found in more than 100 over-the-counter pills, gel caps, liquids and lozenges used for coughs and colds. Oftentimes, what’s more concerning than the DXM itself is the other ingredients the medicines contain, such as acetaminophen, the generic form of Tylenol, or antihistamine. Too much acetaminophen can cause liver failure, while too much antihistamine can cause high blood pressure, seizures and abnormal heart rhythms.

The problem is, many of the people abusing DXM products don’t understand that they need to choose products that don’t contain ingredients like acetaminophen and antihistamine, Hendrickson said.

“They just know that they usually buy a certain color box,” he said, “and if the drug store doesn’t have that color box, they just get the other color.”

St. Charles Health saw only four emergency room visits due to DXM overdose between October 2015 and the end of September. Sergi said one of the overdoses referred to Rimrock took place in Portland, even though the patient is local, and one was this month. In fact, she said all of the patients referred to Rimrock for DXM overdoses live in Deschutes County.

“It’s been completely out of the ordinary,” she said, “and it’s been kind of back-to-back as well.”

There is no antidote for a DXM overdose. Once people end up in the emergency room, there is little doctors can do for them aside from trying to make them comfortable, including giving them sedatives to bring down their heartrate, blood pressure and agitation. In serious cases, doctors place the patients on ventilators if their mental status is such that they can’t maintain their breathing or keep their airways open.

Dr. Gillian Salton, an emergency physician with Central Oregon Emergency Physicians who works at St. Charles Bend, said one of the most important things doctors do for patients who’ve overdosed on DXM is simply keeping them safe.

“People’s reality testing and judgment is completely gone,” she said, “and so they do things like leap into traffic or jump off bridges or things that are a significant risk to themselves or others.”

There is no test for DXM, so often doctors aren’t sure what they’re dealing with.

Attempts at regulation

DXM was first developed as a nonaddictive substitute for codeine, an ingredient that’s no longer in most over-the-counter products. Even so, people for decades have raised concerns about the potential for teens to abuse it, a pastime dubbed robotripping, skittling, dexing or triple C.

Back in 1990, petitions in Pennsylvania and Utah urged the FDA to address the issue of teens overdosing on the medicine. Ultimately, FDA committee members assigned to the subject couldn’t agree on the extent of the problem or what could be done about it.

The FDA in 2005 issued a public warning about products containing DXM following the deaths of five teenagers in Washington state, Florida and Virginia. All of the teens, ages 17 to 19, were found to have consumed DXM in its pure, powered form that an Indianapolis company had purchased from India, repackaged and sold online.

That year, there were 7,603 DXM-related emergency room visits nationally, according to the Drug Enforcement Agency. In 2008, the latest year for which data could be obtained, that number was nearly 8,000, down from 10,410 the previous year.

In 2007, the DEA requested that the FDA assess DXM’s pharmacology and gather abuse data so it could consider whether to classify the drug as a controlled substance. Ultimately, the DEA decided not to label the drug as a controlled substance.

Gateway into experimentation

A common theme Sergi noticed among all of the adolescents referred to Rimrock Trails is DXM was their first exposure to substance abuse.

“These are kids that don’t have a history of smoking pot, of drinking alcohol, of abusing any other substances,” she said. “It was kind of their gateway into experimentation.”

Heather Kennedy, Rimrock’s outpatient counselor and intake coordinator, estimates between 30 percent and half of her agency’s clients have abused DXM at some point.

Marijuana is still the drug of choice among Rimrock’s clients, Sergi said.

Generally speaking, it’s rare to see someone abusing DXM long term, Hendrickson said. In fact, he said a large proportion of people who try the drug find they don’t enjoy the experience.

“We don’t see the 40-year-old who has been using it for 25 years,” he said. “We see 15-year-olds who are trying it, and it goes poorly.”

Hendrickson suspects young people gravitate toward DXM because they’re too young to buy alcohol or other drugs, or the illicit drugs are too difficult to access. Plus, cold medicine is legal, he said. You won’t get in trouble for having it in your pocket or backpack.

Parents should take note of empty bottles or cartons of cough and cold medicine, Hendrickson said.

“Your readers should know that if they have a teenager that this is happening, and they probably know people who do this,” he said. “It’s not a totally foreign concept to teenagers. It’s relatively frequent, and it seems to cause a lot of visits to the ER.”

Parents often don’t realize kids can get high off of cold medicine, Kennedy said.

“Parents imagine drugs as very specific things,” she said. “It hadn’t crossed their minds that they should lock those drugs up or keep them out of reach.”

— Reporter: 541-383-0304,